Provider Demographics
NPI:1568502920
Name:JACQUE, KEITH (RPH)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:JACQUE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13377 WOODLAND CT
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-9448
Mailing Address - Country:US
Mailing Address - Phone:231-796-3871
Mailing Address - Fax:
Practice Address - Street 1:2608 GOVERNMENT CENTER DR
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-8302
Practice Address - Country:US
Practice Address - Phone:989-802-0354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2022-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029749183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist